Mr. M is just 50 years old, but the year before our team met him he had been hospitalized 3 times, each admission caused by an exacerbation of a different chronic medical problem. And though he spent nearly a month of that year as an inpatient, he often missed his outpatient appointments, didn’t take his medications regularly, and was about to lose his already marginal housing. Symptoms from his congestive heart failure, diabetes and other medical conditions kept him from being able to walk more than a block or do basic activities.

As health care professionals at San Francisco General Hospital, we work with many patients in Mr. M’s situation: individuals with severe chronic disease, substance use, mental illness, functional impairments, difficulty with self-management, lack of social support, and marginal housing. Many do not speak English. We know this combination of factors often leads to a frustrating outcome: though Mr. M had access to primary care, he still had very poor health and was hospitalized often.

Studies on the elderly, mentally ill, and homeless have demonstrated how an interdisciplinary team employing coaching techniques can improve care and decrease hospital stays. We hoped that if we used a similar approach to directly address the factors contributing to Mr. M’s poor health, we could better support him. So we designed a primary care-based program for frequently hospitalized patients: the General Medicine Clinic Care Management Program. Our team, which includes a full-time registered nurse and medical assistant health coach, as well as part-time support from a coordinator, a social worker, and a physician, provides more comprehensive care than traditional primary care and aims to improve health and reduce hospitalizations for patients like Mr. M.

When Mr. M joined our program, the backbone of our team – our care management nurse, Fern Ebeling, RN, and medical assistant health coach, Lisa Tang – visited his home. They discovered Mr. M was motivated to learn, wanted to get better, and had a good, supportive friend. However, they also found he did not understand how his various diseases affected his health, how to manage his medical conditions, or how to compensate for his functional impairments. Although he was disabled, he had gotten lost in the disability application process and did not have benefits. Due to prior negative life experiences, had a general lack of trust in others. After spending time together, Mr. M and the team created a care plan that included his goals—to feel better and to reapply for disability benefits—as well as our goals of increased understanding of his medications, cardiac diet adherence, counseling about methamphetamine addiction, and diabetes self management.

To achieve these long-term goals, Fern knew that, “We had to find common ground… At first, he really needed the structure of weekly visits, both for building trust and for monitoring.” These visits did not focus solely on medical concerns, nor did they divert from a team approach to care. Since our program is embedded in the General Medicine Clinic at SFGH, his primary care doctor was part of the team and contributed to the care plan goals. Within a few weeks, the team social worker, Lindsey Evans, successfully taught him how to apply for disability benefits and worked with him to find housing with his friend. As the physician lead on our team, I identified medications that could be titrated, was available for clinical back up, and helped to prioritize his many care plan goals.

Despite initial hesitation, after three months of weekly visits or telephone conversations Mr. M began to engage and even reach out to us when he had concerns. This is typical. “The fact that people can call us and talk to the same people every time they call, that is a part of how people know that we are there for them,” Fern explains. This program feature is representative of the personal and collaborative characteristics that drive the model, as is providing support systems that allow patients to become self-advocates.

A few months into working with us, it became clear that things were changing for Mr. M. Though his primary care doctor had worked with Mr. M for years, she remarked that it “was the first time I had seen him stable. He looked like a different person!”

As Mr. M stabilized and took on responsibility for his own care, such frequent interaction became unnecessary. Even though we now coach Mr. M monthly instead of weekly, Mr. M has continued to improve. Since enrolling in the General Medicine Clinic Care Management Program, he has had no emergency room visits or hospital admissions and has attended the majority of his scheduled appointments.

Mr. M’s positive experience is not unique. On average, patients in our program have had fewer costly contacts with the health care system —49% fewer hospital days and 21% fewer ER visits after enrollment in the program. One of our patients shared: “For me [the care management team] were my angels because when I needed it the most they were always with me.” Because we want to ensure we always have the patient’s perspective front and center, an advisory board of enrolled patients helps guide the General Medicine Clinic Care Management Program’s development. Thus far, they have given very positive feedback about their experience.

In the era of health care reform, financing of medical care is shifting from paying for visits to paying for quality care. Public hospitals, with their long history of caring for complex, vulnerable patients, now have an opportunity to lead innovative models of care for these populations. Model programs like ours have the potential for a “triple win”: to improve patient care, save money through decreases in hospitalizations and ER visits, and create new roles and even jobs for nurses, medical assistants, community health workers, social workers, and other health professionals. Based on our successful experience, we hope to see these models of care flourish in the future.